Impact of venous thromboembolism chemoprophylaxis on postoperative hemorrhage following operative stabilization of spine fractures.

BACKGROUND: Prophylactic anticoagulation may decrease the risk of venous thromboembolism (VTE) in patients with spine fractures following blunt trauma but comes with the threat of postoperative bleeding in patients requiring stabilization of these fractures. The purpose of this study was to evaluate the impact of preoperative anticoagulation on VTE and bleeding complications in patients with blunt spine fractures requiring operative stabilization. METHODS: All patients with blunt spine fractures requiring operative stabilization over a 6-year period were identified. Patients with a hospital stay of less than 48 hours or missing data were excluded. Patients were stratified by age; severity of shock, spinal cord injury, fracture location, injury severity; and timing and duration of anticoagulation. Outcomes included bleeding complications (wound hematoma/infection and development of epidural hematoma) and VTE (pulmonary embolism and deep venous thrombosis). Outcomes were evaluated to determine risk factors for bleeding complications and VTE in the management of operative spine fractures. RESULTS: Seven hundred five patients were identified: 355 patients received one dose or more of preoperative anticoagulation, and 350 did not receive preoperative anticoagulation. Seventy-two percent were male, with a mean injury severity score and Glasgow Coma Scale score of 21 and 14, respectively. Bleeding complications occurred in 18 patients (2.6%), and 20 patients (2.8%) had VTE. Patients with VTE were more severely injured (Glasgow Coma Scale score of 13 vs 15, p ≤ 0.001 and injury severity score of 27 vs 18, p = 0.008). Despite longer time to mobilization (4 vs 2 days, p < 0.001), patients who received 50% or more of their scheduled preoperative doses had fewer episodes of pulmonary embolism (0.4% vs 2.2%, p < 0.05), with no difference in bleeding complications (2.1% vs 2.9%, p = 0.63) compared to patients who received either no preoperative anticoagulation or less than 50% of their scheduled preoperative doses. CONCLUSIONS: Preoperative anticoagulation in patients with operative spine fractures reduced the risk of pulmonary embolism without increasing bleeding complications. Preoperative anticoagulation is both safe and beneficial in patients with operative spine fractures. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Impact of early operative pelvic fixation on long-term self-reported outcome following severe pelvic fracture.

BACKGROUND: Traumatic disruption of the pelvic ring is a significant cause of life-threatening hemorrhage. For those patients who survive the initial injury, these fractures are associated with long periods of immobilization and intense rehabilitation. There is little published information available regarding long-term functional outcomes in these patients. This study evaluated the impact of severe pelvic fractures on those long-term outcomes. METHODS: All patients with severe pelvic fractures over an 18-year period were identified. Severe pelvic fractures were defined as those with vascular disruption, open-book component with symphysis diastasis, or sacroiliac disruption with vertical shear. Functional outcome was measured using the Boston University Activity Measure for Post-Acute Care to assess mobility (normal, >84) and daily activity (normal, >84). Multiple linear regression analysis was used to identify predictors of functional outcome after severe pelvic fracture. RESULTS: From January 1996 to September 2014, 401 patients were identified: 240 (60%) men and 161 (40%) women. Overall mortality was 29%. Of the 285 survivors, follow-up was obtained in 145 patients (51%). Mean follow-up was 8.3 years, with a maximum of 20 years. Mean age and Injury Severity Score were 53 years and 27, respectively. Mean Activity Measure for Post-Acute Care scores for mobility and daily activity were 55 and 63, respectively; both signifying significant impairment when compared with normal. Multiple linear regression analysis using age, traumatic brain injury, transfusions, Injury Severity Score, ventilator days, presence of associated lower-extremity fractures, and time to operative pelvic fixation identified time to pelvic fixation as the only predictor of decreased mobility (ß = -0.74, p = 0.04) and activity (ß = -0.21, p = 0.03) following severe pelvic fracture. CONCLUSIONS: Prolonged time to operative pelvic fixation led to worse long-term functional outcomes in patients with severe pelvic ring disruption. Early fixation of the pelvic ring is the only potentially modifiable risk factor for decreased functional outcomes in patients with severe pelvic fractures. LEVEL OF EVIDENCE: Therapeutic study, level IV.